WSMA WSMOS Preparing for ICD-10 for ICD 10 Lott.pdf · WSMOS Preparing for ICD-10 • ICD-9-CM is more than 3 decades old: Running out of code numbers Uses outdated terminology Insufficient

WSMAWSMOS Preparing for ICD-10

WSMOS Preparing for ICD-10

Michelle M. Lott, CPC, CPMA Health Insurance Coding Specialist, WSMA

Bob Perna, MBA, FACMPESenior Director, WSMA Practice Resource

CenterPhone: 206.441.9762

800.552.0612Email: [email protected]

[email protected] 2


Agenda• Overview of ICD-10-CM/ICD-10-PCS• ICD-10 For Oncology• Preparing and Planning for ICD-10

Implementation• Clinical Documentation Improvement• Strategies for Successful Implementation

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• ICD-9-CM is more than 3 decades old: Running out of code numbers Uses outdated terminology Insufficient specificity/detail Insufficient for reporting new medical

technologies• Has a direct impact on:

Quality of our nation’s health care data Ability for U.S. to maintain global clinical data

comparability

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Benefits of the ICD-10 Coding System• Measure the quality, safety, and efficacy of care• Reduce the need for attachments to explain the

patient’s condition• Design payment systems and process claims for

reimbursement• Conduct research, epidemiological studies, and

clinical trials• Support operational and strategic planning• Design health care delivery systems• Monitor resource utilization

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Benefits of the ICD-10 Coding System• Improve clinical, financial, and administrative

performance• Prevent and detect health care fraud and abuse• Track public health and risks

Possible Delay of ICD-10-CM• HHS’s statement follows remarks by CMS Acting

Administrator, Marilyn Tavenner, that CMS would “reexamine the pace” of the ICD-10 implementation. On February 15, 2012, Health and Human

Services (HHS) Secretary Kathleen G. Sebeliusannounced that HHS will initiate the rulemaking process to postpone the compliance deadline for implementation of ICD-10-CM/PCS.

• On April 9, 2012 the proposed rule change was announced delaying ICD-10-CM by 1 year; Implementation: October 1, 2014


Updates to ICD-9-CM & ICD-10-CM• Last regular annual update for ICD-9-CM and

ICD-10-CM/PCS: October 1, 2011

• Limited updates for ICD-9-CM and ICD-10-CM: October 1, 2012 and October 1, 2013

• Update resumption: October 1, 2014


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What is ICD-10-PCS?• Procedural coding system for inpatient

procedures only for facility coding Developed by CMS Replaces the third volume of ICD-9-CM Does not replace CPT/HCPCS for outpatient

procedure codes

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• ICD-10-CM Versus ICD-10-PCS ICD-10-CM used in both the outpatient and

inpatient setting. ICD-10-PCS used only in the Inpatient Setting

• ICD-10-PCS requires a new set of definitions of medical terms related to institutional procedures.

• Used only in the United States• Requires more Anatomy and Physiology• Medical Terminology• Pathophysiology

A Comparative Overview - StructureICD-9-CM ICD-10-CMDifferences Differences

Three (3) to five (5) characters Three (3) to seven (7) characters

First digit is numeric or alpha (E or V) First digit is alpha

2nd, 3rd, 4th, 5th digits are numeric 2nd and 3rd digits are numeric; 4th, 5th, 6th, 7th digits can be alpha or numeric

No placeholder Placeholder “x”

Similarities Similarities

Always at least three (3) characters All categories are three characters

Decimal placed after first three (3) characters

Decimal placed after the first three (3) characters

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ICD-10-CM Structure Definitions


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ICD-10-CM Structure Definitions



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•Example: Weeks of Gestation = Z3A

4th, 5th and 6th Characters

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•Example: Poisoning by, adverse effect of an underdosing of Penicillins = T36.0

•T36.0x1 – Poisoning by Penicillin, Accidental•T36.0x2 – Poisoning by Penicillin, Intentional self-harm•T36.0x3 – Poisoning by Penicillin, assault•T36.0x4 – Poisoning by Penicillin, undetermined•T36.0x5 – Adverse effect of Penicillin•T36.0x6 – Underdosing of Penicillin

Always alpha

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•Example: Open Wound of Head = S01• S01.01: Laceration with foreign body scalp•Code requires 7th character to indicate initial encounter




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ICD-10 for Oncology• The "ICD-10-CM Official Guidelines for

Coding and Reporting" includes a section on coding guidelines for neoplasms. Most notably, the ICD-10-CM sequencing

guideline for anemia associated with malignancy.• When admission/encounter is for management

of an anemia associated with the malignancy, and the treatment is only for anemia, the appropriate code for the malignancy is sequenced as the principal or first-listed diagnosis.

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ICD-10 for Oncology• Sequencing of neoplasm codes (I.C.2.l.1.

thru I.C.2.l.6.) Encounter for complication associated with a

neoplasm (I.C.2.l.4.)– When encounter is for management of a complication

associated with a neoplasm, and treatment is only for the complication, the complication is coded first, followed by the appropriate neoplasm code.

– Exception to this guideline is anemia:» When admission/encounter is for management of anemia

associated with malignancy and treatment is only for anemia, malignancy should be sequenced first as the principal (first-listed) diagnosis followed by D63.0 –Anemia in neoplastic disease.

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ICD-10 for Oncology• Because neoplasms can occur anywhere in

the body, coding professionals might wonder where to begin refreshing their anatomy and pathophysiology knowledge. This is going to be essential for hospital billing

departments that have to implement ICD-10-PCS.

• Morphology Codes Morphology codes are no longer listed in the

Alphabetic Index alongside the descriptors and standard ICD-10-CM codes.

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ICD-10 for Oncology: Neoplasms (C00-D48)• ICD-10-CM Specific guidelines are:

Guidelines I.C.2 General neoplasm guidelines Guideline I.C.2.a Treatment directed at the malignancy Guideline I.C.2.b. Treatment of secondary site Guidelines I.C.2.c. Coding and sequencing of

complications Guideline I.C.2.d. Primary malignancy previously

excised Guidelines I.C.2.e. Admissions/encounters involving

chemotherapy, immunotherapy and radiation therapy Guidelines I.C.2.l. Sequencing of neoplasm codes

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ICD-10 for Oncology• ICD-10-CM provides codes for reporting

neoplasm sites with greater precision. In some instances, ICD-10-CM provides greater

detail on the type of neoplasm for malignant neoplasms and for benign and other histologicbehaviors.

• Chapter 2 in ICD-9-CM contains nearly 960 codes and Chapter 2 in ICD-10-CM contains more than 1,540 codes.

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ICD-10-CM for Oncology• Documentation requirements for neoplasms

require specificity in both the site and laterality components. Type Malignant (Primary, Secondary, Ca in situ) Benign Uncertain Unspecified behavior Location(s) (site specific) If malignant, any

secondary sites should also be determined Laterality, in some cases

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ICD-10-CM for Oncology• Example: Malignant neoplasm of the breast

has 54 choices, and requires specification of male/female breast, the site of the neoplasm on the breast, and laterality. In addition, a code for estrogen receptor status is required, if known. Code example: C50.411 Malignant neoplasm of

upper-outer quadrant of the right female breastand Z17.1 Estrogen receptor status negative status [ER-].

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ICD-10-CM Oncology • Diagnosis: Invasive ductular carcinoma of

breast, completely excised. ICD-9-CM Code: 174.9

ICD-10-CM Code: C50.412 Rationale: Neoplasm; breast; female; upper

outer quadrant left breast. It is important to note that location is very specific in ICD-10-CM with laterality also an issue, good documentation for specificity is required for proper code assignment.

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ICD-10-CM For Oncology• In ICD-10-CM, primary malignant neoplasm of

the prostate is code C61, which is a one-to-one match with ICD-9-CM code 185. However, for metastatic prostate cancer, codes

for the site of the metastasis are more specific.• Secondary sites requiring more specificity

include the lungs (C78.01 right or C78.02 left), kidneys (C79.01 right or C79.02 left), other urinary organs, bone and bone marrow (C79.51 bone or C79.52 bone marrow), adrenal glands (C79.71 right or C79.72 left).

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Does ICD-10-CM/PCS Affect Cancer Registrars?

• Cancer registrars use a list of cancer diagnosis codes assigned by coders to identify cases of reportable neoplasms. Some registries also include complication and

comorbidity codes.• Chapter 2 in ICD-10-CM corresponds to the

ICD-O-3 codes already used by cancer registries.

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ICD-10-CM for Oncology• Lymphoma and Leukemia

Code categories for lymphoma include: C81 Hodgkin lymphoma, C82 Follicular lymphoma, C83 Non-follicular lymphoma, C84 Mature T/NK-cell lymphomas, C85 Other specified and unspecified types of non-Hodgkin lymphoma, C86 Other specified types of T/NK cell lymphoma.

The increased code specificity for follicular lymphomas (Code category C82) includes identification of the grade.

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ICD-10-CM for Oncology• Neoplasms of the Liver

In ICD-10-CM there are unique codes for liver cell carcinoma, hepatoblastoma, angiosarcomaof liver, and other sarcomas of liver.

When coding these conditions in ICD-10-CM, it is useful to have an awareness of the different codes for primary malignant neoplasms of the liver.




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Organizational Planning Create an organizational planning body Build a Transition Project Plan Develop a Communication Schedule for

Stakeholders Identify organizational “champion” for ICD-10-CM

transition Project Issue Log

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Information Technology Readiness Conduct IT Landscape Assessment

• Front & Back-end Applications• Clinical Programs

–EHR–Registries

• Reporting & Tracking Programs• Other

–Servers–Workstations

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Information Technology Readiness Assess IT Operational Readiness

• EHRs• Meaningful Use• Clinical Improvement Programs• Staffing Needs

System implementation readiness• Clearinghouses • PM systems• Software Upgrades• Vendor Assessment

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Operational Readiness Identify operational data flows as well as

process workflows w/in those impact areas Assess organizational documentation impacts Assess organizational report/reporting impacts Conduct Clinical Documentation Readiness

Assessment Develop operational contingency plans

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Educational Readiness Develop training strategy Assess all management and staff to identify

appropriate groups who will need training in ICD-10-CM

Assess current skill levels of identified groups Develop training levels based on size of your

organization/skill level of staff Determine who needs additional training beyond

ICD-10-CM code sets

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Educational Readiness Determine training modalities Determine who will provide training and where Determine training time requirements

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Financial Readiness Evaluate productivity impact Assess External Party Readiness Develop transition project budget Develop operating budget going forward

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Financial Readiness• Sustainability in the face of potential financial

impacts Delayed payments due to utilization of new codes Increase in account receivables Cash flow/line of credit risks due to possible

negative revenue cycle impacts Industry estimates indicate there could be up to a

five-year stabilization of cash flow post ICD-10 cut over.

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Financial Readiness - Mitigation • Establish a solid financial baseline/revenue

cycle up front• What does our operation look like today with

ICD-9?• What things do I need to think about from a

modeling standpoint going forward?• What do I need to monitor on the back end?




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• Clinical Documentation Improvement (CDI) - General ICD-10-CM and ICD-10-PCS offer much more

specificity because of the expansion of codes. • While it is still possible to assign nonspecific

codes, it is imperative that the most specific code be reported to maximize ICD-10-CM/PCS's ability to provide meaningful data on patient care and severity.

• Current documentation practices should be assessed and a plan developed to improve health record documentation.

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• Conduct Clinical Documentation Improvement (CDI) Assessment - Identify high frequency diagnoses Monitor for a 6-12 month period pre-

implementation Identify and target “risk” areas for clinical

documentation improvement Integrate findings into coder training and

compliance program Focus educational feedback for physicians/other

clinicians

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• Documentation Improvement Program First, run a report in your computer system and

sort it by diagnosis code. Next, start with your top ten and run another

report listing patients that had those diagnoses appended to them.

Pull 10 to 20 charts with your top used diagnosis code.

Review the ICD-10-CM guidelines (if there are any) for the chapter in which the diagnosis is located. Then, review the notes for diagnosis ONLY.

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• Documentation Improvement Program Look at the history and the assessment and code

it under ICD-10-CM. Put together a report based on the diagnosis: how many notes could be coded under ICD-10-CM?• How many notes need more specific

information to code? • How many notes had to be coded to an

unspecified code? Take these findings to each provider and review

them to show the specificity in ICD-10-CM and what is needed in the documentation to support the diagnosis.

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• Documentation Improvement Program Depending on how well the provider did on the

assessment, you may either perform another assessment on the same diagnosis, or move on to the next diagnosis on your "top ten" list.

The facility/office should have a target percentage for the assessments that all providers should meet.

Reports should be kept on each assessment to show progression of the providers.

Do repeat assessments!

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• Documentation Improvement Program Once the assessments begin, they should

continue until the implementation date of October 1, 2014.

How often they occur depends on the number of providers you have, the number of different specialties, the type of specialties, and how the providers perform.

When you start to officially use the code set, then it will become part of the regular audit process.

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• Documentation Improvement Program –Challenges The cumbersome, manual processes for

identifying cases for daily reviews. Once case reviews are underway, the physician

query process can present some of the most daunting challenges in the CDI program.

Inaccessibility of physicians. Excessive time required for ongoing follow-up

with physicians to ensure that responses and suggested changes are received.

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• Documentation Improvement Program –Challenges Lack of system integration. Lack of appropriate management tools needed

for tracking, monitoring and reporting the CDI process.

Costs of having a Consultant conduct the review




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Strategies for successful Implementation of ICD-10 CM

• Make the Case for Relevance Demonstrate through outreach education the

key points (above) about the impacts that ICD-10 will have on physicians and their offices.

• Make the Case for Good Documentation Beyond coding, good documentation is just

good practice. New documentation requirements are not unreasonable and in general are consistent with best practices for medical assessment and decision making.

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• Find a Physician Champion Physicians respond better to colleagues or other

physicians with shared medical practice understanding.

With the proper support, these champions can help bring this message forward and help develop training efforts.

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• Don’t Try to Turn Physicians into Coders Physicians should focus on what they are

trained to do. Coders should focus on proper documentation

and use their knowledge of the codes available and the definition and rules to assist Physicians.

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Resources• CMS – www.cms.gov/ICD10• National Center for Health Statistics –

www.cdc.gov/nchs/icd.htm• American Academy of Professional Coders (AAPC)

– www.aapc.com• American Hospital Association (AHA) –

www.aha.org• American Health Information Management

Association (AHIMA) – www.ahima.org• Workgroup for Electronic Data Interchange (WEDI)

– www.wedi.org

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Questions?

Documents

WSMA WSMOS Preparing for ICD-10 for ICD 10 Lott.pdf · WSMOS Preparing for ICD-10 • ICD-9-CM is more than 3 decades old: Running out of code numbers Uses outdated terminology Insufficient